What’s wrong with emergency care in Aneurin Bevan Health Board? Dr Danny Antebi & Dr Julie Vile

“We have seen an increase in the 85+ age group” “The acuity of our patients is increasing” What do we know / think? TOO MUCH DEMAND PROCESSES ARE TOO SLOW IN HOSPITAL LACK OF CAPACITY TO TAKE PATIENTS OUT OF SYSTEM “The system is in crisis” With increased demand, bed cuts and no immediate prospect of additional funding, we need a FUNDAMENTAL change if we hope to deliver a high quality service

Demand for A&E services

Demand by age band

A&E age profile (adults)

A&E outcome – admitted

Hospital profile: co-morbidities

Hospital profile: age & beddays

Projections for 65+ AB residents with dementia

The 4 hour target

The 8 hour target

4 hr Breaches & Death Rate

Ideas for modelling/ alleviating the problem TOO MUCH DEMAND PROCESSES ARE TOO SLOW IN HOSPITAL LACK OF CAPACITY TO TAKE PATIENTS OUT OF SYSTEM Admission avoidance strategies Better community model Role of WAST Consultant at front end Alternative pathway for elderly/ frail patients Co-locate MIU Better computational facilities Discharge patients earlier Bring in elective patients later 24/7 working Patient boarding

Ideas for modelling/ alleviating the problem TOO MUCH DEMAND PROCESSES ARE TOO SLOW IN HOSPITAL LACK OF CAPACITY TO TAKE PATIENTS OUT OF SYSTEM Admission avoidance strategies Better community model Role of WAST Consultant at front end Alternative pathway for elderly/ frail patients Co-locate MIU Better computational facilities Discharge patients earlier Bring in elective patients later 24/7 working Patient boarding

Choluteca Bridge

The problem Evidence of repeated escalation, increased clinical incidents, stories of poor care, queues of ambulances. So…  Case for change  Organisational focus  Conceptual framework

Case for change Internal to health, partners in delivery, public and politicians Making the case  Data  Hearts and minds  Patient safety

Organisational focus Leadership Whole system approach Prioritise Emergency Care

S afe T imely E ffective E fficient E quitable P atient Centred S ystemic C ollaborative D ialogue Improvement Innovation

Conceptual framework Flow Complexity Networks and Matrices

Flow Poor flow harms and kills (Kate Sylvester-mortality by day of admission) Poor flow wastes resources Demoralises staff Impacts on other departments

Complicated or complex Simple - following a recipe Complicated - building a space rocket  First 48 hours CVA, cardiac surgery Complex - raising a child  Chronic conditions, plus dementia plus NOF

Slide on differences

Production lines and pathways Acute chest pain  Expertise, latest equipment, excellent process, minimal collaboration, safe environment Complicated pathway/Organisational ownership Chronic cardiac failure and cognitive impairment  Stay at home, response, support, advice when I need it, a lot of collaboration, engage my family, friends and the milkman, occasional high tech Complex approach/Shared ownership

Networks and matrices Resilient communities public/private/3 rd sector – with a shared agenda and priority ? integration IT, budgets, management

Research and modelling Flow - patient safety, risk, right person, right place, right time, right expertise, pull not push Complexity – process measures less outcome measures, dignity, patients who can’t report Networks – organisational collaboration, resilient and robust community and primary care, risk assessment and management, EOL/anticipatory care.

Thank you for listening! Any questions?